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Undergraduate Magazine: Understanding the Psychology of Pain

For pre-med student Jessica White, the decision to major in psychology provided an opportunity to gain insight into the complexities of pain.

By David Miller
Fall 2013
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White going over the Universal Pain Assessment Tool with a patient.

Pain management can go beyond medication and a doctor’s assessment of physical responses, as one University of Alabama student recently discovered.

Just as personalities differ from person to person, each individual’s brain processes and responds to pain differently. Most research, however, on psychological indicators contributing to a patient’s prognosis
and treatment is limited. Conversely, physiological indicators are more commonly used, particularly in emergency rooms, to assess pain levels and treat patients who suffer from chronic pain.

Jessica White, a pre-med psychology major who graduated from UA in May 2013, spent her junior and senior years studying the trends of self-reported pain scores and physiological indicators at DCH Regional Medical Center in Tuscaloosa. With the help of Shweta Kapoor, a third-year doctoral student at UA, and Dr. Beverly Thorn, chair of UA’s Psychology Department and director of the department’s pain lab, White interviewed 90 patients with pain at the DCH emergency department. She discovered that many of the patients she interviewed had self-reported pain scores that didn’t match their physiological responses.

“You’d think the two would correlate,” White said. “It’s still surprising to me. It wasn’t until I read an article about the difference in the two responses that I knew there was a difference. It’s been extremely rewarding to conduct this research, especially when I see so many people [in the emergency room].”

White can empathize with many of the patients who suffer chronic pain and frequent the emergency room at DCH. Since she was a young child, White has had a gait abnormality in which the dropping of the forefoot happens due to weakness and damage to the peroneal nerve or paralysis of the muscles in the anterior portion of the lower leg. The nerve damage White suffered caused her right leg to grow slower than her left. As a result, she’s endured multiple surgeries and chronic pain over the years. While she manages her pain well and has done everything from walk in high heels to star on her high school volleyball team – feats once thought impossible – she admits that she had a naive perspective of how others deal with chronic pain.

White presented her research poster at the Society of Behavioral Medicine conference in San Francisco in 2013. She also took first place in the natural sciences/mathematics division of UA’s 2013 Undergraduate Research and Creative Activity Conference. Additionally, she received an award for Significant Contributions to Undergraduate Research in Psychology from UA’s psychology department and $300 in undergraduate research travel awards from the College of Arts and Sciences.

“Before I started this, I’d see someone in pain and think, ‘Well, I know how I’d react to this; you’re overreacting,’” she said. “But I realize that it is not necessary that they would experience pain as I experience it; it’s a completely different experience for each of us. That’s what I’ve learned from doing this research.

“I wanted to understand what kinds of things influenced pain experience in individuals with pain. Also what does someone with chronic pain experience that someone else with acute pain may not? It’s been a complete learning experience because I didn’t know much about pain. I wanted to learn everything there is about pain.”

Two factors enabled White to gain access to the DCH emergency department: her status as a UA psychology honor’s research student and her prior relationship with the doctors there, which she had cultivated through her job as a scribe. In that position, White collaborated with emergency room physicians and fulfilled the primary secretarial and nonclinical functions of the busy physician or mid-level provider. After spending a year working as a scribe, doctors trusted White to adhere to confidentiality laws and not disrupt the flow of patients in the ER.

There were some challenges getting approval from institution review boards, which recommended modifications so that the study would not disrupt patient care. It took about seven months before White could begin interviewing patients. But she stuck with it.

“This is a much bigger project than most of our honors students take on,” said Thorn. “We thought about pulling the plug a couple of times waiting for final approvals, and I was already starting to talk with her [White] about another project she could take on.”

Once the study finally began, White had to follow strict parameters during the interview process, which she could not conduct personally while she was on duty as a scribe or even during her off hours if she’d worked earlier in the day. Researchers could not approach patients in the waiting room; patients were brought from the waiting room to triage, where vitals were taken and questions were asked. At that point, the triage nurse would offer patients the chance to participate in the pain study. Patients were ineligible for the study if they were less than 19 years old or if they were taken to the trauma hall.

Interviews took place in another room, where researchers asked participants multiple questions, such as how they would rate their pain on a scale of one to 10.

“We got the patients before they saw the doctor, and always before they were given pain medicine of any kind,” Thorn said. “We gave them different psychological measures to gauge their level of anxiety and the amount of catastrophic thinking they had regarding the pain.”

Jessica White spent her junior and senior years studying the trends of self-reported pain scores and physiological indicators at DCh Regional Medical center in tuscaloosa.

White said patients’ pain types varied between acute and chronic. Acute pain typically lasts no longer than three to six months and can be caused by things like a broken bone or a sinus infection. Chronic pain is long-term and can be caused by things like a bulging disk in one’s back, chronic muscle tension or irritable bowel syndrome, which can lead to chronic abdominal pain.

Though White and her team found that many of their participants did not show the elevated vital signs commonly expected to be associated with pain – elevated heart rate and blood pressure – they found other interesting associations. For example, people with higher pain reports tended to have higher levels of catastrophic thinking about their pain, although they were no more anxious about being in the emergency room than those with lower pain reports.

“One of the things we already know but wanted to reiterate is these people have real pain; their vitals may not show it, but it doesn’t mean they’re faking it at all,” Thorn said. “What it means is that psychological variables affect how we feel pain, very profoundly.”

Another key to helping the underserved pain population is doctor and nurse awareness. Kapoor said nurses sometimes rely on a person’s physiological indicators to determine their pain levels, but it’s important to find out what other factors are driving

the patient’s pain experience. What are the psychological variables, and how are the patients thinking about their pain? The next step is to address those variables.

“If we can design interventions to reduce some of the psychological factors associated with higher pain levels,” said Kapoor, “we will ultimately support both the patient and the medical team providing emergency care.”

Before attending medical school, White is taking a year off to travel, including a month-and-a-half-long medical internship in Madurai, South India, that began in August. When she does become a doctor, her experience at UA will have given her a unique understanding of her patients’ experience of pain, one that goes well beyond what an x-ray, a blood test or vital signs can indicate.